Pbv Application Packet - Housing Authority Of Snohomish County (Page 33 of 38) in pdf

OMB No. 2577-0266

Expires 08/31/2016

U.S. Department of Housing and Urban Development

Office of Public and Indian Housing

DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS

Paperwork Reduction Notice: Public reporting burden for this collection of information is estimated to average 7 minutes

per response. This includes the time for respondents to read the document and certify, and any recordkeeping burden. This

information will be used in the processing of a tenancy. Response to this request for information is required to receive

benefits. The agency may not collect this information, and you are not required to complete this form, unless it displays

a currently valid OMB control number. The OMB Number is 2577-0266, and expires 08/31/2016.

NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:

Public Housing (24 CFR 960)

Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982)

Section 8 Moderate Rehabilitation (24 CFR 882)

Project-Based Voucher (24 CFR 983)

The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public

Housing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily or

involuntarily terminated participation in one of the above-listed HUD rental assistance programs. This information is

maintained within HUD’s Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies (PHAs)

and their management agents to verify employment and income information of program participants, as well as, to

reduce administrative and rental assistance payment errors. The EIV system is designed to assist PHAs and HUD in

ensuring that families are eligible to participate in HUD rental assistance programs and determining the correct

amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD

regulations at 24 CFR 5.233.

HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at the

conclusion of your participation in a HUD rental assistance program. This notice provides you with information on what

information the PHA is required to provide HUD, who will have access to this information, how this information is used

and your rights. PHAs are required to provide this notice to all applicants and program participants and you are

required to acknowledge receipt of this notice by signing page 2. Each adult household member must sign this form.

What information about you and your tenancy does HUD collect from the PHA?

The following information is collected about each member of your household (family composition): full name, date of

birth, and Social Security Number.

The following adverse information is collected once your participation in the housing program has ended, whether you

voluntarily or involuntarily move out of an assisted unit:

1. Amount of any balance you owe the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed

(i.e. unpaid rent, retroactive rent (due to unreported income and/ or change in family composition) or other charges

such as damages, utility charges, etc.); and

2. Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and

3. Whether or not you have defaulted on a repayment agreement; and

4. Whether or not the PHA has obtained a judgment against you; and

5. Whether or not you have filed for bankruptcy; and

6. The negative reason(s) for your end of participation or any negative status (i.e., abandoned unit, fraud, lease

violations, criminal activity, etc.) as of the end of participation date.

08/2013

Form HUD-52675

Pbv Application Packet - Housing Authority Of Snohomish County Page 33

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